Health Select Committee: inquiry into Clearing the backlog caused by the pandemic

Evidence Submission from the Royal College of Anaesthetists to the Inquiry on Clearing the backlog caused by the pandemic

About the Royal College of Anaesthetists

The Royal College of Anaesthetists (RCoA)^{^[1]} is the third largest medical royal college by UK membership. With a combined membership of over 24,000 fellows and members, we represent the three specialties of anaesthesia, intensive care and pain medicine.

Anaesthetists of all grades play a critical role in the care of two-thirds of hospital patients, including those affected by COVID-19. Anaesthetists and intensivists, alongside their colleagues, have found themselves at the centre of this crisis and have had to learn and adapt at pace to provide the best possible care for the sickest COVID-19 patients under very challenging circumstances.

The RCoA is submitting evidence to this inquiry as the specialty of anaesthesia has been central in tackling the pandemic and will continue to play a critical role in the recovery and addressing waiting lists. The evidence submitted consists of insights and findings from wide ranging work through our policy influencing activities (campaigns^{^[2]}, surveys, reviews, etc.).

Executive summary

The below written evidence covers issues and needs relating to the elective backlog caused by the pandemic. This includes:

An extensive and growing waiting list of patients awaiting treatment that is set to rise to over 9 million by 2023/24.
A serious shortage in the anaesthetic workforce, which is especially concerning as anaesthetists have been essential on the front line during the pandemic and will continue to be essential for dealing with the backlog and recovery of the NHS. The shortfall is currently approximately 1,400 anaesthetists, which could lead to 1 million delayed operations per year.
A call for perioperative care to be formally implemented across the NHS as a solution for dealing with the backlog as well as a permanent way of delivering patient care that has proven benefits in patient outcomes and cost effectiveness.
Positive lessons from the pandemic around cross-skilling, leadership and communication, decision making and digital innovation that demonstrate how the NHS was able to adapt to an unprecedented crisis.

What is the anticipated size of the backlog and pent-up demand from patients for different healthcare services including, for example, elective surgery; mental health services; cancer services; GP services; and more widely across the healthcare system?

Cancellation of elective surgery during the pandemic has led to a considerable backlog. According to NHS waiting list figures, as of June 2021, more than 5.4 million^{^[3]} patients are on the NHS waiting lists awaiting treatment and this number continues to rise. Considering people who have not yet come forward or who have not yet been referred for hospital treatment, the waiting list could rise to a figure of 9.7 million^{^[4]} by 2023/24.

Longer waiting times will result in advanced disease and greater deconditioning of patients, and this makes a clear case for perioperative care to be adopted for optimising and managing these patients. This means different healthcare professionals working together, and with patients, to optimise medical conditions and fitness ahead of surgery to achieve the best outcomes. Fitter patients experience fewer complications after surgery and recover more quickly. We believe that perioperative care will help reduce the unmet need, using existing skills and expertise within the NHS to reduce variation and improve patient outcomes after surgery.

What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?

There are not enough anaesthetists to deal with the elective surgery backlog in a timely fashion to meet the needs of patients. In the second reading of the Health and Care Bill 2021-22^{^[5]} a current workforce gap of 1,400 anaesthetists was highlighted. In practice, this could lead to 1 million delayed operations per year.

Data collected through the latest RCoA Medical Workforce Census 2020^{^[6]} paints a downward trend for the UK anaesthetic workforce. Our Census estimates that over the next 2 years, over 2,300 additional trained anaesthetists will be needed to staff anaesthetic departments such that they can cope safely with demand. However, we estimate that only around 700 new anaesthetists will qualify over the next two years.

Data and information drawn from the 2020 workforce census and 2015 Centre for Workforce Intelligence (CfWI) modelling^{^[7]} have been used to estimate a baseline and to forecast future anaesthetist demand and supply over 20 years. This analysis estimates that, in the base case, the size of the anaesthetic workforce would need to rise from 10,710 FTE to 15,044 FTE from 2020 to 2040 in order to meet demand for anaesthetic services. Without considering the current growth and trajectory of supply, this is equivalent to 216.7 FTE per year on average from 2020 to 2040. Figure 1 presents the projections for base case supply.

This type of workforce modelling will be critical to identify where early intervention will be required, with consideration of the length of medical training, to allow the NHS to continue to provide the best care for a growing and ageing population and deliver the objectives of the Long-Term Plan ^{^[8]}.

Anaesthesia Associates (AAs) are allied health professionals who can provide high quality, safe care as part of a multi-professional team, led by a consultant anaesthetist. AAs do not replace their medical colleagues but can complement service provision. This would help reduce fatigue and burnout by offering a much needed boost to the anaesthetic workforce. However, AAs are a medium-term solution as there are currently very few of them (173 recorded in the most recent census), limited training capacity and considerable time needed to train them (27 months).

Retention of staff should be prioritised to keep the people needed to tackle the backlog in work longer. This will require looking into the issues which may cause anaesthetists to leave the profession and make solutions to retain staff. A survey carried out on retention issues in anaesthesia found that the following would encourage anaesthetists to stay working in the NHS for longer or return after retiring:

being able to work flexibly and less than full time to have better work-life balance
reduced or no overnight on-call work
contract flexibility
being able to adjust clinical practice or the environment to account for physical changes with age
having supportive colleagues and managers that are respectful and appreciative
advice about pay, pension and taxation issues

There also needs to be sufficient bed capacity: the Royal College of Surgeons of England have recommended in their 'A New Deal for Surgery' report^{^[9]} an increase in the number of hospital beds from 2.5 to 4.7 per 1,000 people, in line with the OECD average.

We urgently need increased critical care capacity across the UK. The UK has one of the lowest critical care bed to population ratios in Western Europe^{^[10]}. When the pandemic hit, a great deal of time and effort was spent reorganising wards and operating theatres to cope with the influx of COVID-19 patients requiring intensive care, leading to the suspension of or reduction in the delivery of elective care even for urgent and time-critical treatments such as cancer.

Providing enhanced care areas^{^[11]} can ensure that patients are placed in the right area dependent on the severity of their condition as they may be too ill to be cared for on the ward but may not require critical care.

How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?

The Centre of Perioperative Care (CPOC)^{^[12]} is a cross-specialty centre led by the RCoA which is dedicated to the promotion, advancement and development of perioperative care, for the benefit of both patients and the healthcare community.

CPOC has made a separate written submission to this inquiry which the RCoA fully endorses.

CPOC has published comprehensive evidence^{^[13]} which shows that the perioperative pathway is associated with higher quality clinical outcomes, reduced financial cost and better satisfaction for surgical patients.

Using perioperative approaches we can help ensure that patients are ready for their surgery for when the NHS is ready for them. Additionally, the system of ‘waiting lists’ for major surgery should be changed and replaced by ‘preparation lists’^{^[14]}. This is more reflective of the period before the patient goes for surgery being time they should be using to make effective lifestyle changes that will aid recovery after surgery.

We need transformed processes for the delivery of planned surgery that use the core principles of CPOC, Getting it Right First Time^{^[15]} and the British Association of Day Surgery^{^[16]} not only to deliver safe and effective care, but to also support the NHS in ‘building back better’.

Day surgery encompasses a spectrum of surgical procedures that allows the patient to go home on the day of surgery, usually after a few hours. In the National Day Surgery Delivery Pack^{^[17]}, reconfiguration or redevelopment of services to increase the level of day surgery for at least the 200 procedures was identified by BADS. If day surgery becomes the norm, this would be highly cost-effective, improve efficiency, improve staff retention and morale and reduce the demand for inpatient beds.

Perioperative care cannot be made possible unless the funding and staffing is put in place. We are keen to work with the Treasury to fund rapid implementation of perioperative care pathways, and to improve funding of medical research to focus on other aspects of perioperative care where the evidence remains lacking or unclear.

The RCoA supports the Committee’s recommendation to the Government to include provisions in the Health and Care Bill for production of robust workforce requirement forecasts across the health and care service and for responding to the recommendations on the investments for the workforce required to meet the needs of an ageing population with increasing complex care needs.

The Government is committed to training 4,000 more GPs and 50,000 more nurses. While there is a clear need for addressing shortages in these areas, there is currently no consistent workforce planning across all healthcare professions and there is a real risk that shortages in other less high profile specialties will be overlooked, until they reach critical levels. We welcome the recent announcement by Health Education England to review its strategic framework for workforce planning.

Critical care capacity should be a key priority for building back an NHS that can cope with future pandemics and surges, for example through the expansion of postoperative care units and the adoption of the enhanced care model ^{^[18]} to improve patient flow, support operative scheduling and release capacity within critical care for the patients who need it most.

What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?

Cross Skilling
The pandemic has seen staff working outside their usual professional scope of practice, for example, working alongside colleagues in intensive care. Cross-skilling has been critical to enabling staff, including anaesthetists, to be redeployed safely to Intensive Care Units (ICUs), with 50% of respondents in our April 2020 COVID-19 survey ^{^[19]} saying they had received cross-skilling training. In the COVID-19 winter survey^{^[20]}, 53% of members said they had learnt new, transferrable skills during the pandemic.

As it is highly likely that we will see recurring peaks of infection and new variants of COVID-19, it is critical that we maintain the skills gained so that the NHS can be better prepared for predicted surges and difficult winters going forward. Just by offering regular training or rotation of different roles in relevant care settings, such as enhanced care units, we can maintain the knowledge gained and build a pool of ‘reservists’ who can quickly step up to support ICUs when needed.

Leadership and communication
At the start of the pandemic the RCoA, the Association of Anaesthetists, the Faculty of Intensive Care Medicine, and the Intensive Care Society set up an online hub ^{^[21]} to provide guidance specific to anaesthesia and intensive care. It became evident very quickly that there was a large amount of information and guidance available from different sources and different countries, but little time and capacity for clinicians to extract the useful information and critical lessons. Hospitals and other health and social care settings could have benefited greatly from a co-ordinated approach to the sharing of learning between countries early on in the pandemic, especially in this era of digital communications and social media platforms.

The pandemic has also demonstrated the value of collaboration between national organisations. Royal Colleges have worked successfully with regulators and NHS leaders to co-ordinate guidance and responses as situations arose. This level of alignment should endure to ensure that clear messaging and strong leadership remain a critical component of the response to future surges.

Decision making
A reduction in bureaucracy and top-down management during the pandemic have made staff feel empowered and have enabled faster implementation of plans for local services. This is a demonstration of the importance of clinical input in decision making and proof that clinical leadership at a local level can bring about positive change quickly for the benefit of patients and staff. In its response^{^[22]} to the Department of Health and Social Care consultation on busting bureaucracy^{^[23]}, the College stressed the need for clinical governance mechanisms to foster innovation, by way of streamlining approval routes and sign-off procedures.

The urgency of the COVID-19 pandemic has accelerated the simplification of decision-making and governance, and we should continue to dismantle barriers within systems to improve morale and develop leadership amongst NHS staff.

Digital and technology
The pandemic saw an increase in the use of digital and remote communications across the NHS. For instance NHS Digital ^{^[24]} reported a rise in GP telephone appointments because face-to-face appointments could not be conducted in the first few months of the pandemic. Although many face-to-face appointments have now resumed, phone appointments are likely to remain a key part of the work of GPs. NHS staff have also benefited from educational activities and events delivered through online platforms, such as the Faculty of Pain Medicine’s recently launched FPM Learning ^{^[25]}, an online Pain Medicine education hub. These platforms offer content such as webinars, learning modules and training courses that have been optimised to allow users to continue to gain credits for continuing professional development and access training virtually, avoiding the need to travel to attend face-to-face events during social distancing restrictions.

COVID-19 has accelerated the pace of digital innovation and we should continue to make the best of these new tools where appropriate, while remaining mindful of the needs and preferences of individual patients, particularly those who may not have access to technology.

What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?

All systems should recognise the potential for digital innovation as well as consider the best approach to implement them into healthcare. Digital innovation allows creation of virtual multidisciplinary teams, more extensive consultation across healthcare sectors and integrated single points of access that have the potential to reduce waiting times, minimise journeys to hospitals and support the delivery of the right care at the right time. There has also been progress towards digital aspirations such as remote monitoring to enable better self-management and improved outcomes. However, there is the risk of increasing the potential for health inequalities if the use of digital innovation marginalises patient groups that may not have effective access to these technologies.

NHS leaders and national bodies should be more open to Trusts and other NHS organisations being more involved in taking decisions about how they care for their communities. There should be a review of reporting and measurables that hospitals are required to do and consideration into whether they are all necessary.

Access to patient information across the healthcare service can facilitate perioperative care. This is due to the importance of shared decision making where patients have a more involved role in their care working with healthcare staff.

[1] www.rcoa.ac.uk

[2] https://www.rcoa.ac.uk/policy-communications/policy-public-affairs/covid-19-campaign

[3] https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2021/08/RTT-statistical-press-notice-Jun21-PDF-410K-69343.pdf

[4] https://www.health.org.uk/publications/long-reads/managing-uncertainty

[5] https://www.parallelparliament.co.uk/mp/jeremy-hunt/bill/2021-22/healthandcare

[6] https://www.rcoa.ac.uk/training-careers/working-anaesthesia/workforce-planning/medical-workforce-census-report-2020

[7] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/507348/CfWI_Anaesthetics_ICM_main_report.pdf

[8] https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

[9] https://www.rcseng.ac.uk/about-the-rcs/government-relations-and-consultation/position-statements-and-reports/action-plan-for-england/

[10] https://www.kingsfund.org.uk/publications/critical-care-services-nhs

[11] https://www.ficm.ac.uk/sites/default/files/enhanced_care_guidance_final_-_may_2020-.pdf

[12] https://cpoc.org.uk/